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Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome
Maria N Gamaletsou1, Blandine Rammaert2, Marimelle A Bueno3
1Weill Cornell Medical Center of Cornell University, New York, NY, USA; National and Kapodistrian University of Athens, Athens, Greece; Center for Osteoarticular Mycoses, Hospital for Special Surgery, New York, NY, USA; International Osteoarticular Mycoses Study Consortium, USA.
Background:
The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.
Methods:
Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.
Results:
Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).
Conclusions:
Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.
Insights
Aspergillus osteomyelitis is a serious bone infection impacting immunocompromised and immunocompetent individuals. Optimal management combines antifungal therapy and surgery to prevent relapse and ensure recovery.
Area of Science:
- Infectious Diseases
- Orthopedics
- Mycology
Background:
- Aspergillus osteomyelitis remains poorly understood regarding its epidemiology, pathogenesis, diagnosis, and treatment.
- This study addresses the knowledge gaps in managing this debilitating bone infection.
Purpose of the Study:
- To comprehensively review and synthesize existing literature on Aspergillus osteomyelitis.
- To identify key factors influencing clinical presentation, diagnosis, and treatment outcomes.
Main Methods:
- A systematic review of protocol-defined cases of Aspergillus osteomyelitis in the English literature.
- Analysis of patient comorbidities, microbiological data, infection mechanisms, clinical and radiological findings, biomarkers, therapies, and outcomes.
Main Results:
- 180 patients were analyzed; 71% were male, and 57% had predisposing conditions like immunosuppression or neutropenia.
- Common infection sites included vertebrae (46%), cranium (23%), and ribs (16%). Vertebral cases often involved spinal-cord compression (47%).
- Combined antifungal therapy and surgery (67%) significantly reduced relapse rates (8%) compared to antifungal therapy alone (30%), with an overall mortality of 25%.
Conclusions:
- Aspergillus osteomyelitis is a severe infection affecting immunocompromised and immunocompetent patients, frequently involving vertebrae, ribs, and cranium.
- Optimal management involves a combination of antifungal therapy and selective surgical intervention.
- This approach is crucial for preventing relapse and achieving successful patient outcomes.
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